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SWRCB, January 2002 DEC 0 J �' <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary , W ' Use tAT <br />appropriate pages of thisfornt to report results for all components tested The completed form, wri tiRA5p-Ind <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Pilot Flying J - Frazier Park #618 Date of Testing: 11/01/2016 <br />Facility Address: 1501 Jack Tone Rd. Ripon, CA 95366 <br />Facility Contact: Manager Phone: 209-599-4141 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): N/A <br />2. TESTING COIF <br />Company Name: Jones Covey Group, Inc. <br />Technician Conducting Test: Joseph Gonzalez <br />Credentials: IN CSLB Licensed Contractor <br />License Type: A, a and Naz <br />11 SWRCB Licensed Tank Tester <br />License Number: 804431 <br />Manafsctnrer Training <br />nnnnuiacturer Uom ones s Date Training Ex ices <br />INCON- TS -STS 9037453707 04/30/2017 <br />1CC 8341128 03/14/2017 <br />i_ QYTMMARV>7Tt"Y`T 4ZrV DR-CTTi TG <br />Component <br />Pass Fail Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass Fail Not <br />Tested <br />Repairs <br />Made <br />Tank #1 Diesel Annular <br />0 <br />❑ <br />EM <br />❑ <br />UDC 1-2 <br />i& <br />❑ <br />0 <br />0 <br />Tank #2 Diesel Annular <br />0 <br />❑ <br />lg) <br />❑ <br />UDC 3-4 <br />is <br />❑ <br />❑ <br />❑ <br />Tank #3 Diesel Annular <br />❑ <br />❑ <br />IM <br />❑ <br />UDC 5-6 <br />P1 <br />❑ <br />❑ <br />p <br />Tank #4 87 Annular <br />11 <br />1 ❑ <br />IA <br />❑ <br />UDC 7-8 <br />Ig <br />0 <br />p <br />❑ <br />Tank #5 91 Annular <br />❑ <br />❑ <br />IN <br />❑ <br />UDC 9-10 <br />19 <br />0 <br />0 <br />❑ <br />Tank #6 Diesel Annular <br />0 <br />❑ <br />IM <br />❑ <br />UDC 11-12 <br />►� <br />❑ <br />o <br />❑ <br />Tank #1 Diesel STP <br />IN <br />❑ <br />❑ <br />❑ <br />UDC 13 <br />❑ <br />p <br />p <br />Tank #2 Diesel STP <br />IN <br />0 <br />0 <br />0 <br />UDC 14-15 <br />® <br />0 <br />p <br />p <br />Tank #3 Diesel STP <br />ill <br />❑ <br />❑ <br />❑ <br />UDC 16 <br />® <br />p <br />p <br />❑ <br />Tank #4 87 STPig <br />❑ <br />p <br />❑ <br />UDC 19 main <br />❑ <br />IM <br />0 <br />p <br />Tank #5 91 STP <br />0 <br />® <br />❑ <br />❑ <br />UDC 19 satellite <br />❑ <br />A <br />❑ <br />p <br />Tank #6 Diesel STP <br />❑ <br />® <br />❑ <br />❑ <br />UDC 20 main <br />❑ <br />IN <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />"Water was recycled In water trailer for future re -use. <br />CERTIFICATION OF TECBMCIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: ` Date: 11101/2016 <br />